Infant feeding in emergencies
no title Fiona O'rielly 26.04.97
Re: Infant feeding in emergencies - BMS David Alnwick 26.04.97
DSM/sugar/oil mixes Peter Sullivan 26.04.97
Infant feeding in emergencies Peter Sullivan 27.04.97
Re: Infant feeding in emergencies - BMS -Reply Rita Bhatia 27.04.97
no title Fiona O'Reilly 28.04.97
Re: Recipes for Infant feeds in emergencies Lola Nathanail 28.04.97
infant feeding in emergencies Michael H.N. Golden 28.04.97
DSM/sugar/oil recipe Andy Seal 28.04.97

Sat, 26 Apr 1997 16:59:23 +0100 (BST)

From: (Fiona O'rielly)

Subject: no title


At one of the 'infant feeding in emergencies' meetings held at SCF participants felt that there was a need for recommendations on recipes for alternatives to Breast milk and Infant formula, for infants under 6 mths. It was recognised that if breast milk was not available for the under 6 month old child then marketed Infant formula was most appropriate. However the wider public health implications of using this product reduced its suitability. It was concluded that either as a stop gap measure or in some cases as an alternative to infant formula that recipes using either local products or relief items would be useful for field workers in this area.

I want to give examples of appropriate recipes for Breast milk substitutes in the Emergency Nutrition Network Newsletter. Could participants comment on the recipes below as to their suitability or give other examples or references on appropriate resources. ( For those who do not already know about the ENN see attached document.)

1. Full cream powdered milk for babies up to 3 mths

milk powder: 1 level teaspoon

boiled water: 30mls

sugar: 1 level teaspoon per feed

daily requirements: 150mls of the mix per kg body weight per 24 hrs vol. per feed one fifth of daily total at each of five feeds at four hourly intervals

2. Full cream powdered milk for babies over 3 months old

milk powder: 1 rounded teaspoonful

boiled water: 30mls

Sugar: 1 level teaspoonful per feed

daily requirement 150 ml of the mix per kg body weight per 24 hours vol. per feed one fifth of daily total at each of five feeds at four-hourly intervals

3. Dried Skimmed Milk - for infants up to 3 months

Ingredients for 1 litre

DSM: 50 gm

Sugar: 50gm

Cereal Flour: 30gm ( any type, but flour from root crops e.g. cassava is not suitable)

Vegetable oil: 30gm

Citric acid: 5gm (fruit juice)

Water: 900ml




Fiona O'Reilly, Emergency Nutrition Network

Department of Community Health & General Practice

199 Pearse Street, Trinity College

Dublin 2, Ireland

Tel: 353 1 608 2676 Fax 353 1 670 5384, email:

Date: Sat, 26 Apr 1997 20:38:26 -0400

From: (David Alnwick)

Subject: Re: Infant feeding in emergencies - BMS


Others more knowledgeable than me on the science will no doubt comment, but I suggest that the recipes suggested would be quite dangerous, especially for the youngest infants. If a young infant cannot be breastfed, and if a safe alternative source of breastmilk cannot be found, then a good pre-formulated 'breast-milk substitute', prepared according to the latest US or EU recommendations or the CODEX ALIMENTARIUS guidelines, will be the next best thing. This should be distributed in 'generically labelled' containers, and fed with a cup and spoon, not a bottle. The breastmilk substitute manufacturers have struggled for over 50 years to perfect their product, they have certainly not come close to breastmilk and probably never will, but I think we have to give them credit for making a product which will be more conducive to the growth and survival of a young infant than a 'home brewed' mixture of milk powder and sugar in a situation where breastmilk is not an option.

Often the most difficult and expensive part of an emergency operation is often reaching people and getting things to them - with the right kind of management and control. I believe it would be possible to produce arguments that would show that the difference in total cost of trying to keep a young infant alive and growing on a 'home' recipe compared to the cost of providing the same 'care' together with a well formulated 'breast-milk substitute' would be rather small. In many recent emergencies the transport costs alone for food have been very high and have often exceeded the world market price for the food itself - this is an additional argument for delivering the highest possible quality food.


This is a quickly prepared informal note sent to 'NGOUT' as a contribution to the debate, and it does not represent or imply a formal or final UNICEF position on this subject.

Date: Sat, 26 Apr 1997 10:39:20 +0000

From: (Peter Sullivan)

Subject: DSM/sugar/oil mixes


Mike Golden makes the point (see: milk and scurvey) that DSM/sugar/oil mixes by themselves are not appropriate diets for severely malnourished children and must have an appropriate mineral/vitamin mix added to them. This is particularly important for children who have persistent diarrhoea as well as malnutrition (PDM); in The Gambia we showed that the small intestine in children with PDM was severely damaged and that the damage was not rectified after at least 4 and often 6 weeks feeding in hospital with skim milk/sugar and oil mix. There have been no studies

looking at the effect of more sophisticated feeds such as F-100 with micronutrient supplements on restitution of intestinal integrity after nutritional rehabilitation but it is quite possible that treatment failures or relapses after apparent rehabilitation relate, at least in part, to continued small intestinal dysfunction. As a first step, longitudinal follow-up data six months after treatment for severe malnutrition with F-100 or similar "recipes" would be useful.

Peter B. Sullivan


Dr Peter B Sullivan MA MD FRCP FRCPCH

University of Oxford, Department of Paediatrics, John Radcliffe Hospital

Oxford OX3 9DU, UK

Tel: Int-44-1865-220934, Fax: Int-44-1865-220479


Sun, 27 Apr 1997 10:52:03 +0100

From: (Peter Sullivan)

Subject: Infant feeding in emergencies


With respect to Fiona O'Reilly's request for feedback on the "recipes" for emergency feeding, I am very concerned about the dangers (eg tetany) inherent in feeding recipe 1 to infants under 3 months of age. It is not possible to accurately assess the nutritional adequacy of this recipe because the measures (one teaspoon etc) are too imprecise, nevertheless, it is very likely that this recipe is very inadequate with too much protein, sodium, phosphorus, too high an osmolar load, too little iron and Vitamin C etc. Maybe Jeya Henry could help with a more detailed analysis?

I realise, of course, that in an emergency situation, this recipe may be the only alternative and better than nothing but this is a well travelled route and the history of finding alternatives to mother's breast milk is an integral part of the history of paediatric medicine itself. With so much known now about the appropriate formulation of milk feeds for young infants can we not do better even in the emergency sector?


Dr Peter B Sullivan MA MD FRCP FRCPCH

University of Oxford, Department of Paediatrics

John Radcliffe Hospital, Oxford OX3 9DU, UK

Tel: Int-44-1865-220934, Fax: Int-44-1865-220479


Date: Sun, 27 Apr 1997 19:26:37 +0200

From: Rita Bhatia <>

Re: Infant feeding in emergencies - BMS -Reply


Refrence above , it is good to note the concerns being raised in the meeting. But I am afraid to recommend such receipies which may do harm than usefulness.

David Alnwick stated in his message regarding the Breast Milk Sub , David can you send us more information. Has this been practiced in any emergency situation etc etc.

This is a very crucial issue we all face.

Let us try to keep each other updated.



Mon Apr 28 11:07 BST 1997

From: (Fiona O'rielly)


Thanks to those answering the infant feeding in emergencies question. Home made recipes including the ones in my last e-mail are given in some of the current manuals on Infant Feeding and Management of Feeding programmes (references available if anyone is interested). If consensus is, as it seems to be that 'home made' recipes are dangerous and their use should be avoided at all costs, then it would seem that efforts among relief agencies should concentrate on having immediate access to generically labelled infant formula for situations where it is not possible for infants to be breast fed. Along with this should go guidelines on appropriate targeting of this BMS. In practice I'm not sure that appropriate BMS is available on the ground when it is required, we have field experiences reported from agency personnel

in Rwanda working with unaccompanied minors highlighting that among the commodities available from donors this item was not included. More information on appropriate BMS for use in emergencies would be appreciated.

Fiona O'Reilly

Emergency Nutrition Network, Department of Community Health & General Practice

199 Pearse Street, Trinity College

Dublin 2, Ireland

Tel: 353 1 608 2676 Fax 353 1 670 5384, email:

Mon, 28 Apr 1997 12:41:11 +0100


Subject: Re: Recipes for Infant feeds in emergencies


I note with interest and absolute respect the various comments (alarms!) regarding 'home recipes' for alternatives to breast milk or infant formula. Could I please attempt to put this work into context, as I think this might allay some of the concerns raised: Over the last year or so, an ad hoc group of agencies/individuals concerned about the issue of infant feeding in emergencies have been meeting to discuss policy, strategic and operational issues around this subject. This goes beyond the 'classical' African emergency, to address concerns in dealing with the ever-increasing number of unaccompanied infants, or population groups (such as Easter Europe or Central Asia) who do not normally breastfeed. As an attempt to assist field workers and programme managers in building appropriate programmes, we wanted to devise a triage for decision-making. Thus, breastfeeding would be the first and best option; followed by, in descending order, wet-nursing, local purchase of infant formula, importation of generic infant formula and, lastly, emergency measures to fill any 'gaps' in the flow of supplies. It is in this last category that home-made recipes would fit, to avoid situations where infants are fed CSB because nothing else was available. The point of circulating the recipes was to ensure that they would not be dangerous (although it was accepted that they are far from optimal) - for example, recipes cited in Cameron and Hofvander's Manual on Feeding Infants and Young Children were regarded as clearly inadequate.

David Alnwick's point about mode of feeding - ie cup (and spoon or saucer?) rather than bottle - is also key to the discussion.

I hope this helps put the work on home recipes into context.


Lola Nathanail

Policy Unit, The Save the Children Fund

Subject: infant feeding in emergencies.

Date: Mon, 28 Apr 1997 12:17:48 +0100 (BST)

From: "Michael H.N. Golden" <>


I do NOT think that the recipes put forward by Fiona O'Reilly are at all suitable except in-extremis. I would not publish these formulations in a newsletter that is going out to field workers where they may be taken as endorsed recipies.

Fiona's message raises a number of critical points.

1) Misdiagnosis of current malnutrition in the 0-6 month old infant. Within this age group, low ATTAINED weight-for-height/height-for-age is dominated by the effects of intrauterine growth. (in fact it took 18 months for the effect of birth weight to drop out of a multiple regression analysis of contributing factors to current weight-for-height in Jamaica).

When we select children for intervention on the basis of current attained anthropometry instead of dynamic measures of growth we will include may infants that are in fact catching up on maternal (extra-uterine) care.

The scales that are usually used in emergency situations (100g increments) are insufficiently precise to decide if very small infants are indeed catching up, are static or are loosing weight within a reasonable time frame.

For these reasons I have seen infants admitted to programs who would probably be much better off left alone to be breast-fed without intervention.

If the child has a lactating mother I think that we have to demonstrate a) that there is indeed inadequate catch-up by taking precise repeated measures of growth and b) exclude any non-dietary source of failure to grow such as congenital syphilis, toxoplasmosis etc, before we should even contemplate putting the child onto breast-milk substitutes. The scales and skills to do this are not generally available.

There must be a very very good and cogent reason for putting any infant that has a lactating mother onto any formula diet. I am concerned that the hard data upon which the SCF meeting based its conclusion about the need to breast milk substitutes is suspect and that decisions are being made on inappropriate grounds. Clearly, studies of underlying causes and outcomes of severely malnourished infants within this age group in a refugee setting are needed to inform us of the REAL requirement for substitutes.

2) Where there is no lactating mother, a serious and concerted effort to get a wet nurse should be part of the program.

3) Where there is no lactating mother and no wet nurse, then the infant will need to get a breast-milk substitute. This should be an exceptional circumstance. Here I agree with David Alnwick that commercial formulations IN PLAIN unbranded containers fed with a CUP AND SPOON should be used. DSM and DWM can give rise to problems in the young infant - not the least of which is intestinal iron loss, gastritis, calcium/phosphorus imbalance, hyperosmolal loads etc. DSM based diets are deficient in many trace elements and vitamins needed for health.

4) I hesitate to suggest it, because I want to keep the diets that we use for the rehabilitation of severely malnourished children completely and transparently seperate from diets used in the breast-feeding age group, nevertheless, F100 does contain everything (except iron) needed to sustain rapid catch-up growth. The limiting nutritient in F100 when used for infants is likly to be water (and iron). For these exceptional cases we dilute F100 into 2.8 litres instead of 2.0 litres, add iron and give the infants >135 ml/kg/d.

I should point out the F75 is totally inappropritate for infants and is not designed to allow children to grow normally - it is designed for the severely malnourished multiply depleated infected child - it should not be used for infant feeding.

Best wishes,


Prof. Michael H.N.Golden

Date: Mon, 28 Apr 1997 13:55:43 +0100

From: Andy Seal <>


I was interested to see that the DSM/sugar/oil recipe for infant feeding reccomended in the more recent feeding manuals: MSF "Nutrition Guidelines" (1995) and UNICEF (1986) 'Assisting in emergencies' appears not to have mentioned in the discussions so far. [DSM 50g/L; sugar 75g/L; oil 25g/L].

According to the MSF manual 150ml/kg/day would meet the approx. requirements of 105kcal amd 2.8g protein/kg/day.

For stop-gap situations is this recipe now also considered inappropriate in terms of energy and protein content or is the concern with this formulation the only the lack of micronutritent content?


Andy Seal, Research Fellow

Centre for International Child Health, Institute of Child Health

30 Guilford Street, London WC1 1EH

Tel. (0171)242 9789 Ex.2468, FAX (0171)404 2062